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 SOAP Note Rubric 
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                              Criteria                          
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                              Ratings                          
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                              Pts                          
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 This criterion is linked to a Learning OutcomeDemographics 
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                                              1 to >0.8 pts                                          
                                             Begins with patient initials, age, race, ethnicity and gender (5 demographics)                                          
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                                              0.8 to >0.25 pts                                          
                                             Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender)                                          
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                                              0.25 to >0.0 pts                                          
                                             Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender)                                          
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                                              0 pts                                          
                                             Missing criteria and/or submission.                                          
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 1 pts 
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 This criterion is linked to a Learning OutcomeChief Complaint (Reason for seeking health care) 
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                                              4 to >3.0 pts                                          
                                             Includes a direct quote from patient about presenting problem                                          
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                                              3 to >2.0 pts                                          
                                             Includes a direct quote from patient and other unrelated information                                          
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                                              2 to >0.0 pts                                          
                                             Includes information but information is NOT a direct quote                                          
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                                              0 pts                                          
                                             Missing criteria and/or submission.                                          
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 4 pts 
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 This criterion is linked to a Learning OutcomeHistory of the Present Illness (HPI) 
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                                              5 to >3.0 pts                                          
                                             Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)                                          
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                                              3 to >2.0 pts                                          
                                             Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)                                          
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                                              2 to >0.0 pts                                          
                                             Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)                                          
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                                              0 pts                                          
                                             Missing criteria and/or submission.                                          
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 5 pts 
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 This criterion is linked to a Learning OutcomeAllergies 
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                                              2 to >1.5 pts                                          
                                             Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)                                          
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                                              1.5 to >1.0 pts                                          
                                             If allergies are present, students lists type Drug, environmental factor, herbal, food, latex name and includes severity of allergy OR description of allergy                                          
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                                              1 to >0.0 pts                                          
                                             If allergies are present, students lists only the type of allergy name                                          
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                                              0 pts                                          
                                             Missing criteria and/or submission.                                          
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 2 pts 
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 This criterion is linked to a Learning OutcomeReview of Systems (ROS) 
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                                              15 to >8.0 pts                                          
                                             Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”                                          
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                                              8 to >3.0 pts                                          
                                             Includes 3 or fewer assessments for each body system and assesses 5-8 body systems directed to chief complaint AND uses the words “admits” and “denies”                                          
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                                              3 to >0.0 pts                                          
                                             Includes 3 or fewer assessments for each body system and assesses less than 5 body systems directed to chief complaint OR student does not use the words “admits” and “denies”                                          
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                                              0 pts                                          
                                             Missing criteria and/or submission.                                          
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 15 pts 
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 This criterion is linked to a Learning OutcomeVital Signs 
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                                              2 to >1.5 pts                                          
                                             Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)                                          
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                                              1.5 to >1.0 pts                                          
                                             Includes 7 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)                                          
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                                              1 to >0.0 pts                                          
                                             Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with F or C and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)                                          
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                                              0 pts                                          
                                             Missing criteria and/or submission.                                          
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 2 pts 
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 This criterion is linked to a Learning OutcomeLabs 
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                                              2 to >1.5 pts                                          
                                             Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.                                          
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                                              1.5 to >1.0 pts                                          
                                             Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values.                                          
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                                              1 to >0.0 pts                                          
                                             Includes a list of the labs reviewed at the visit but does not include the values of lab results or highlight abnormal values.                                          
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                                              0 pts                                          
                                             Missing criteria and/or submission.                                          
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 2 pts 
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 This criterion is linked to a Learning OutcomeMedications 
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                                              4 to >2.0 pts                                          
                                             Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency)                                          
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                                              2 to >1.0 pts                                          
                                             Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of the 4: name, dose, medications route, frequency)                                          
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                                              1 to >0.0 pts                                          
                                             Includes a list of all of the patient reported medications (including 2 of the 4: name, dose, route, frequency)                                          
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                                              0 pts                                          
                                             Missing criteria and/or submission.                                          
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 4 pts 
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 This criterion is linked to a Learning OutcomePast Medical History 
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                                              3 to >2.0 pts                                          
                                             Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current                                          
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                                              2 to >1.0 pts                                          
                                             Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current                                          
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                                              1 to >0.0 pts                                          
                                             Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current                                          
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                                              0 pts                                          
                                             Missing criteria and/or submission.                                          
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 3 pts 
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 This criterion is linked to a Learning OutcomePast Surgical History 
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                                              3 to >2.0 pts                                          
                                             Includes, for each surgical procedure, the year of procedure and the indication for the procedure                                          
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                                              2 to >1.0 pts                                          
                                             Includes, for each surgical procedure, the year of procedure OR indication of the procedure                                          
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                                              1 to >0.0 pts                                          
                                             Includes, for each surgical procedure but not the year of procedure or indication of the procedure                                          
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                                              0 pts                                          
                                             Missing criteria and/or submission.                                          
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 3 pts 
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 This criterion is linked to a Learning OutcomeFamily History 
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                                              3 to >2.0 pts                                          
                                             Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.                                          
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                                              2 to >1.0 pts                                          
                                             Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.                                          
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                                              1 to >0.0 pts                                          
                                             Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.                                          
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                                              0 pts                                          
                                             Missing criteria and/or submission.                                          
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 3 pts 
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 This criterion is linked to a Learning OutcomeSocial History 
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                                              3 to >2.0 pts                                          
                                             Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.                                          
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                                              2 to >1.0 pts                                          
                                             Includes 10 of the 11 required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.                                          
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                                              1 to >0.0 pts                                          
                                             Includes 9 or less of the required information.                                          
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                                              0 pts                                          
                                             Missing criteria and/or submission.                                          
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 3 pts 
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 This criterion is linked to a Learning OutcomeHealth Maintenance / Screenings 
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                                              3 to >2.0 pts                                          
                                             Includes a detailed assessment of immunization status and other health maintenance needs such as age-appropriate screenings and preventive measures Includes an assessment of at least  
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